Running Training Combined With Blood Flow Restriction Increases Cardiopulmonary Function and Muscle Strength in Endurance Athletes

Effects of blood flow restriction training in athletes: a systematic review and meta-analysis

This systematic review and meta-analysis evaluated the effects of blood flow restriction training on strength and aerobic capacity in athletes, examining how training variables and participant characteristics influenced outcomes. Four databases were searched for peer-reviewed English-language studies, and the risk of bias and the quality of evidence were assessed using RoB 2 and GRADEpro GDT. We evaluated pre- and post-test differences by a three-level meta-analysis using meta and metafor packages. Subgroup analyses and both linear and nonlinear meta-regression methods were used to explore moderating factors. Sixteen studies with "some concerns," the risk of bias and low evidence level, were included. Combining blood flow restriction with low-intensity resistance training produced an effect size of 0.25 for strength, while combining blood flow restriction with aerobic training had an effect size of 0.42. For aerobic capacity, the effect size of combining blood flow restriction with aerobic training was 0.58. Subgroup and regression analyses showed no significant differences. While blood flow restriction with low-intensity resistance training enhances strength, it does not result in additional gains. Combining blood flow restriction with aerobic training enhances both the strength and the aerobic capacity. Overall, blood flow restriction appears to offer the most benefits for male athletes in improving the strength and aerobic capacity.

Proprioceptive neuromuscular facilitation warm-ups: a key to improved isokinetic performance

This study examined the immediate effects of proprioceptive neuromuscular facilitation warm-ups on isokinetic strength, endurance, and body balance in 50 football players. Data collection spanned four sessions, each separated by full rest. The isokinetic strength of the hip, knee, and ankle flexion and extension was measured using a dynamometer at 60°/s, 180°/s, and 240°/s. Endurance was assessed at 240°/s through 25 repetitions, analyzing peak torque changes. On the first day, participants performed general warm-ups followed by balance and strength tests. Subsequent sessions repeated these tests with additional measurements. Results showed that proprioceptive neuromuscular facilitation warm-ups significantly improved the static and dynamic balance compared to other methods. Peak torque measurements at all speeds also highlighted the superior effectiveness of proprioceptive neuromuscular facilitation warm-ups. Additionally, this warm-up approach provided greater acute enhancement in knee joint isokinetic endurance. In conclusion, proprioceptive neuromuscular facilitation warm-ups increased the isokinetic strength, endurance, and balance in football players. Incorporating proprioceptive neuromuscular facilitation warm-ups into football training especially for lower body preparation is recommended. Combining them with active warm-ups may further boost acute performance.

Twenty-five years of blood flow restriction training: What we know, what we don't, and where to next?

Blood flow restriction is a technique that involves inflating a cuff at the proximal portion of the limb with the goal of reducing arterial inflow into the muscle and venous outflow from the muscle. Low-load or low-intensity exercise in combination with blood flow restriction has been consistently shown to augment adaptations over the same/similar exercise without restriction, with changes in muscle size and strength being two of the most commonly measured adaptations. The purpose of this manuscript is to provide an updated narrative review on blood flow restriction. Blood flow restriction's history, methodology, safety, and efficacy are highlighted. We discuss the effects of blood flow restriction on changes in muscle size and strength, and also review work completed on other variables (e.g. bone, resting blood flow, tendon, pain sensitivity, cognition, orthostatic intolerance). We finish by highlighting six possible areas for future research: 1) identifying mechanisms for growth and strength; 2) sex differences in the effects of blood flow restriction; 3) individual responses to blood flow restriction; 4) influence of pressure versus amount of blood flow restricted; 5) application of blood flow restriction with higher-loads; and 6) what considerations should be made to test the effects of blood flow restriction.

The effects of blood flow restriction combined with endurance training on athletes' aerobic capacity, lower limb muscle strength, anaerobic power and sports performance: a meta-analysis

OBJECTIVE

To evaluate the effects of blood flow restriction (BFR) combined with endurance training on aerobic capacity, lower limb muscle strength, anaerobic power, and sports performance to supply effective scientific guidance for training. Two reviewers independently screened the literature, extracted data, and assessed the risk of bias of the included studies. We searched PubMed, Medline, Cochrane, SPORTDiscus and Web of Science databases up to 28 October 2024. Two reviewers independently screened the literature, extracted data, and assessed the risk of bias of the included studies. We calculated the effect size using standardized mean difference values and the random effects model. The results showed a medium effect size on maximal oxygen uptake (V̇O2max), a large effect size on lower limb muscle strength, a small effect size on anaerobic power and sports performance. In conclusion, while BFR training during endurance training had a significant positive effect on lower limb muscle strength and moderate improvement in V̇O2max, its impact on anaerobic power and sports performance was relatively small. These findings suggest that BFR training may be effective for enhancing muscle strength and aerobic capacity, but its benefits on anaerobic power and sport-specific performance may be limited. Therefore, it is important to carefully design BFR training programs to target specific outcomes.

Physiological adaptations and performance enhancement with combined blood flow restricted and interval training: A systematic review with meta-analysis

OBJECTIVES

We aimed to determine: (a) the chronic effects of interval training (IT) combined with blood flow restriction (BFR) on physiological adaptations (aerobic/anaerobic capacity and muscle responses) and performance enhancement (endurance and sprints), and (b) the influence of participant characteristics and intervention protocols on these effects.

METHODS

Searches were conducted in PubMed, Web of Science (Core Collection), Cochrane Library (Embase, ClinicalTrials.gov, and International Clinical Trials Registry Platform), and Chinese National Knowledge Infrastructure on April 2, with updates on October 17, 2024. Pooled effects for each outcome were summarized using Hedge's g (g) through meta-analysis-based random effects models, and subgroup and regression analyses were used to explore moderators.

RESULTS

A total of 24 studies with 621 participants were included. IT combined with BFR (IT+BFR) significantly improved maximal oxygen uptake (VO2max) (g = 0.63, I2 = 63%), mean power during the Wingate 30-s test (g = 0.70, I2 = 47%), muscle strength (g = 0.88, I2 = 64%), muscle endurance (g = 0.43, I2 = 0%), time to fatigue (g = 1.26, I2 = 86%), and maximal aerobic speed (g = 0.74, I2 = 0%) compared to IT alone. Subgroup analysis indicated that participant characteristics including training status, IT intensity, and IT modes significantly moderated VO2max (subgroup differences: p < 0.05). Specifically, IT+BFR showed significantly superior improvements in VO2max compared to IT alone in trained individuals (g = 0.76) at supra-maximal intensity (g = 1.29) and moderate intensity (g = 1.08) as well as in walking (g = 1.64) and running (g = 0.63) modes. Meta-regression analysis showed cuff width (β = 0.14) was significantly associated with VO2max change, identifying 8.23 cm as the minimum threshold required for significant improvement. Subgroup analyses regarding muscle strength did not reveal any significant moderators.

CONCLUSION

IT+BFR enhances physiological adaptations and optimizes aspects of endurance performance, with moderators including training status, IT protocol (intensity, mode, and type), and cuff width. This intervention addresses various IT-related challenges and provides tailored protocols and benefits for diverse populations.

Effects of aerobic training with blood flow restriction on aerobic capacity, muscle strength, and hypertrophy in young adults: a systematic review and meta-analysis

Aerobic training with blood flow restriction (AT-BFR) has shown promise in enhancing both aerobic capacity and exercise performance. The aim of this review was to systematically analyze the evidence regarding the effectiveness of this novel training method on aerobic capacity, muscle strength, and hypertrophy in young adults. Studies were identified through a search of databases including PubMed, Scopus, Web of Science, SPORTDiscus, CINAHL, Cochrane Library, and EMBASE. A total of 16 studies, involving 270 subjects, were included in the meta-analysis. The results revealed that AT-BFR induced greater improvements in VO2max (SMD = 0.27, 95%CI: [0.02, 0.52], p < 0.05), and muscle strength (SMD = 0.39, 95%CI: [0.09, 0.69], p < 0.05), compared to aerobic training with no blood flow restriction (AT-noBFR). However, no significant effect was observed on muscle mass (SMD = 0.23, 95%CI: [-0.09, 0.56], p = 0.162). Furthermore, no moderating effects on the outcomes were found for individual characteristics or training factors. In conclusion, AT-BFR is more effective than AT-noBFR in improving aerobic capacity and muscle strength, making it a promising alternative to high-intensity training.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42024559872.

Effects of blood flow restriction training on aerobic capacity, lower limb muscle strength and mass in healthy adults: a meta-analysis

INTRODUCTION

The aim of this study was to systematically evaluate the effects of blood flow restriction combined with aerobic exercise on aerobic capacity, lower limb muscle strength and mass in healthy adults.

EVIDENCE ACQUISITION

According to PRISMA's statement, we searched Web of science, Medline, Embase, Cochrane library, CNKI, Wan fang, and VIP databases to collect randomized controlled trials on the effects of aerobic exercise with blood flow restriction on improving aerobic capacity, lower limb muscle strength, and muscle mass in healthy adults. The studies were published from the establishment of the database to November 2023. A supplementary search has been conducted on March 8, 2024. Review Manager5.3 and Stata17 were used for statistical analysis.

EVIDENCE SYNTHESIS

A total of 16 RCTs with 388 participants were included. The results of meta-analysis showed: Aerobic exercise with BFR significantly affected aerobic capacity (MD and 95%CI 1.06[0.29,1.83], P<0.05), lower limb muscle strength (MD and 95%CI 7.56[5.80,9.33], P<0.05) and lower limb muscle mass (MD and 95%CI were 3.02[1.63,4.42], P<0.05) in healthy adults. The results of subgroup analysis showed that intermittent pressure was better than continuous pressure (P<0.05). Compared with the elderly, the effect of young and middle-aged was better (P<0.05). At the same time, the training form using power bikes is better than walking or running. Finally, 2-6 weeks, 2-3 sessions per week, 10-45 minutes per session can effectively improve the aerobic capacity of healthy adults.

CONCLUSIONS

Aerobic exercise with BFR can significantly improve aerobic capacity, lower limb muscle strength and mass in healthy adults. In the future, the effects of blood flow restriction training on healthy adults should be further studied, and the form of pressure, intervention cycle, frequency, time, intensity and other variables should be further controlled.

Blood Flow-Restricted Training and Time Trial Performance: A Cohort Study of World-Class Rowers

INTRODUCTION

This study aimed to explore the potential impact of incorporating blood flow restriction (BFR) training within a training block characterized by minimal high-intensity work on 2000-m rowing ergometer time trial (TT) performance in elite/world-class rowers. Physiological markers often associated with endurance performance (maximal aerobic capacity, V̇O 2max ; blood lactate thresholds and hemoglobin mass, Hb mass ) were measured to determine whether changes are related to an improvement in performance.

METHODS

Using a quasi-experimental, observational study design (no control group), 2000-m TT performance, V̇O 2max , submaximal work rates eliciting blood lactate concentrations of ~2 and ~4 mmol·L -1 , and Hb mass were measured before and after 4 wk of noncompetitive season training, which included BFR rowing. BFR training consisted of 11 sessions of 2 × 10 min of BFR rowing at a workload equating to blood lactate concentrations of ~2 mmol·L -1 . Paired t -tests were used to compare pre-/postvalues, and Pearson correlation was used to examine whether physiological changes were associated with changes to TT performance.

RESULTS

TT performance improved in both female (1.09% ± 1.2%, ~4.6 ± 5.2 s; P < 0.01) and male (1.17% ± 0.48%, ~4.5 ± 1.9 s; P < 0.001) athletes. V̇O 2max increased in female rowers only ( P < 0.01), but both sexes had an increase in work rates eliciting blood lactate concentrations of 2 mmol·L -1 (female: 184 ± 16 to 195 ± 15 W, P < 0.01; male: 288 ± 23 to 317 ± 26 W, P = 0.04) and 4 mmol·L -1 (female: 217 ± 13 to 227 ± 14 W, P = 0.02; male: 339 ± 43 to 364 ± 39 W, P < 0.01). No changes in Hb mass (both sexes, P = 0.8) were observed. Improvements in TT performance were not related to physiological changes (all correlations P ≥ 0.2).

CONCLUSIONS

After 4 wk of training with BFR, the improvement in TT performance was greater than what is typical for this population. Physiological variables improved during this training block but did not explain improved TT performance.

Utilization of Blood Flow Restriction Therapy with a Former Triathlete After Total Knee Arthroplasty: A Case Report

Introduction and Purpose

Knee osteoarthritis (OA) is a common condition that limits function and reduces quality of life. Total knee arthroplasty (TKA) is a surgical procedure that replaces the joint surfaces to address anatomical changes due to knee OA. While TKA improves symptoms and function, postoperative impairments are common, including reduced quadriceps strength. Blood flow restriction (BFR) may be a viable option for patients following TKA, as it can improve strength with a minimal amount of joint loading compared to traditional strength training. The purpose of this case report is to describe the impact of BFR use in an individual after TKA, employing pain measurements, quantitative sensory testing, patient-reported outcome measures, physical performance tests, and muscle strength and power testing to explore potential treatment effects and identify potential predictors of response for future studies.

Case Description

A 49-year-old former female triathlete with a history of knee injury and arthroscopic surgery underwent a right TKA and sought physical therapy (PT) due to pain, limited range of motion (ROM), and knee instability during weight bearing activity. PT interventions included manual therapy, gait training, and a home program. Despite participating in supervised PT, she had persistent pain, ROM deficits, and muscle weakness 16 weeks following TKA. BFR was incorporated into her home program, 16-weeks postoperatively. The Short Form McGill Pain Questionnaire-2 (SF-MPQ-2) and Numeric Pain Rating Scale (NPRS) were used to measure pain. Quantitative sensory testing included pressure pain threshold (PPT) and two-point discrimination (TPD) to measure change in sensory perception. Patient-reported outcome measures to assess perceived physical function were the Knee injury and Osteoarthritis Outcome Score (KOOS) and the KOOS- Joint Replacement (KOOS-JR). Physical performance was measured through the 30-second fast walk test (30SFW), timed stair climb test (SCT), 30-second chair standing test (CST), and the timed up and go (TUG). Knee ROM was assessed through standard goniometry. Knee extensor and flexor muscle strength and power were measured with an instrumented dynamometer for isokinetic and isometric testing, generating a limb symmetry index (LSI).

Outcomes

Pain and quantitative sensory testing achieved clinically meaningful improvement suggesting reduced sensitivity during and after BFR utilization. Perceived physical function and symptoms significantly improved, particularly in sports and recreation activities, and were best captured in the KOOS, not the KOOS-JR. Physical performance reached clinically meaningful improvement in walking speed, chair stand repetitions, and timed stair climb tests after BFR. Isokinetic and isometric strength and power in knee extensors and flexors increased significantly after BFR compared to the uninvolved leg as determined by LSI.

Discussion

In this case, BFR appeared to be a safe and well-tolerated intervention. The results suggest potential benefits in terms of increased function, strength, power, and reduced pain in this specific person after TKA. Comprehensive pain and sensory assessments alongside clinical measures may help identify suitable patients for BFR after TKA. The KOOS-Sport & Recreation subscale may be more responsive to monitor functional recovery compared to the KOOS-JR, possibly due to the subject's athletic background.

Level of Evidence

4.

Effects of blood flow restriction training on physical fitness among athletes: a systematic review and meta-analysis

Blood flow restriction training (BFRT) is an effective, scientific and safe training method, but its effect on the overall quality of athletes remains unclear. The aim of this systematic review with meta-analysis was to clarify the effects of BFRT on the physical fitness among athletes. Based on the PRISMA guidelines, searches were performed in PubMed, Web of Science, SPORTDiscus, and SCOUPS, the Cochrane bias risk assessment tool was used to assess methodological quality, and RevMan 5.4 and STATA 15.0 software were used to analyze the data. A meta-analysis of 28 studies with a total sample size of 542 athletes aged 14-26 years and assessed as low risk for quality was performed. Our results revealed that the BFRT intervention had small to large improvements in the athletes' strength (ES = 0.74-1.03), power (ES = 0.46), speed (ES = 0.54), endurance (ES = 1.39-1.40), body composition (ES = 0.28-1.23), while there was no significant effect on body mass (p > 0.05). Subgroup analyses revealed that moderator variables (training duration, frequency, load, cuff pressure, and pressurization time) also had varying degrees of effect on athletes' physical fitness parameters. In conclusion, BFRT had a positive effect on the physical fitness parameters of the athletes, with significantly improved strength, power, speed, endurance and body composition, but not body mass parameters. When the training frequency ≥ 3 times/week, cuff pressure ≥ 160 mmHg, and pressurization time ≥ 10 min, the BFRT group was more favorable for the improvement of physical fitness parameters.

Low- and high-volume blood-flow restriction treadmill walking both improve maximal aerobic capacity independently of blood volume

AIM

Assess the effect of low- and high-volume blood flow restriction training (BFR) on maximal aerobic capacity (VO2 max) and determine if alteration in VO2 max is mediated through changes in hemoglobin mass (Hbmass) and blood volume.

METHODS

Participants' Hbmass (CO-rebreathe), single, and double-leg VO2 max and blood volume regulating hormonal responses (renin and copeptin) were measured before and after BFR training. Training consisted of treadmill walking either (1) twice-daily for 4week (CON and BFRHV ) or (2) twice-weekly for 6week (BFRLV ). Each session consisted of five intervals (3 min, 5% incline, 5 km/h, 100% of lowest occlusion pressure), with 1 min of standing rest between sets.

RESULTS

VO2 max increased using both training exposures, in as quickly as 2-weeks (BFRLV baseline to 4week: +315 ± 241 mL (8.7%), p = 0.02; BFRHV baseline to 2week: +360 ± 261 mL (7.9%), p < 0.01), for the BFRLV and BFRHV groups, with no change in CON. Single- and double-leg VO2 max improved proportionately (single/double-leg VO2 max ratio: BFRLV 78 ± 4.9-78 ± 5.8%, BFRHV 79 ± 6.5-77 ± 6.5%), suggesting that the mechanism for increased VO2 max is not solely limited to central or peripheral adaptations. Hbmass remained unchanged across groups (CON: +10.2 ± 34 g, BFRLV : +6.6 ± 42 g, BFRHV : +3.2 ± 44 g; p = 0.9), despite a significant release of blood volume regulating hormones after initial BFR exposure (renin +20.8 ± 21.9 ng/L, p < 0.01; copeptin +22.0 ± 23.8 pmol/L, p < 0.01), which was blunted following BFRHV training (renin: +13.4 ± 12.4 ng/L, p = 0.09; copeptin: +1.9 ± 1.7 pmol/L, p = 0.98).

CONCLUSION

BFR treadmill walking increases VO2 max irrespective of changes in Hbmass or blood volume despite a large release of blood volume regulating hormones in response to BFR treadmill walking.

An Updated Panorama of Blood-Flow-Restriction Methods

BACKGROUND

Exercise with blood-flow restriction (BFR) is being increasingly used by practitioners working with athletic and clinical populations alike. Most early research combined BFR with low-load resistance training and consistently reported increased muscle size and strength without requiring the heavier loads that are traditionally used for unrestricted resistance training. However, this field has evolved with several different active and passive BFR methods emerging in recent research.

PURPOSE

This commentary aims to synthesize the evolving BFR methods for cohorts ranging from healthy athletes to clinical or load-compromised populations. In addition, real-world considerations for practitioners are highlighted, along with areas requiring further research.

CONCLUSIONS

The BFR literature now incorporates several active and passive methods, reflecting a growing implementation of BFR in sport and allied health fields. In addition to low-load resistance training, BFR is being combined with high-load resistance exercise, aerobic and anaerobic energy systems training of varying intensities, and sport-specific activities. BFR is also being applied passively in the absence of physical activity during periods of muscle disuse or rehabilitation or prior to exercise as a preconditioning or performance-enhancement technique. These various methods have been reported to improve muscular development; cardiorespiratory fitness; functional capacities; tendon, bone, and vascular adaptations; and physical and sport-specific performance and to reduce pain sensations. However, in emerging BFR fields, many unanswered questions remain to refine best practice.

Running interval training combined with blood flow restriction increases maximal running performance and muscular fitness in male runners

We investigated the effects of 8 weeks (3 days per week) of running interval training (RIT) combined with blood flow restriction (RIT-BFR) on the maximal running performance (RPmax), isokinetic muscle strength, and muscle endurance in athletes. Twenty endurance-trained male runners were pair-matched and randomly assigned to the RIT-BFR and RIT groups. The RIT-BFR group performed RIT (50% heart rate reserve, 5 sets of 3 min each, and 1-min rest interval) with inflatable cuffs (1.3× resting systolic blood pressure), and the RIT group performed the same RIT without inflatable cuffs. RPmax, isokinetic muscle strength, and muscle endurance were assessed at pre-, mid-, and post-training. Compared with the RIT group, the RIT-BFR group exhibited a significantly (p < 0.05) greater increase in RPmax, isokinetic knee extensor and flexor strength, and knee extensor endurance after 24 training sessions. These results suggested that RIT-BFR may be a feasible training strategy for improving muscular fitness and endurance running performance in distance runners.